Improving the Provision of Emergency Contraception for Sexual Assault Survivors in the Emergency Department: A Quality and Health Equity Initiative

BACKGROUND: Optimal emergency contraception (EC) can prevent approximately 95% of rape-related pregnancies. However, time to presentation, weight, and BMI influence efficacy of EC, and disparities in access to care, race and ethnicity, language, and socioeconomic status may modify rape-related pregnancy risk. We aimed to increase effective EC administration and eliminate potential health disparities in all sexual assault (SA) survivors managed in the emergency department (ED). METHODS: We conducted a 5-year retrospective review evaluating race and ethnicity, language, selected socioeconomic indicators, and obesity factors in EC administration. We implemented a quality improvement (QI) initiative over 2 years across three urban EDs, with interventions focused on care standardization (e.g., pharmaceutical changes, electronic health record optimizations, and checklists), multimodal and inter-disciplinary education, and sustainability of change (e.g., quality assurance reviews and bi-directional feedback). Statistical process control charts (SPCs) were used to evaluate temporal changes in EC administration to SA survivors. The Pearson Chi-squared was used to analyze differences across race and ethnicity groups in pre- and post-intervention cohorts. We estimated rape-related pregnancy preventions based on estimated pharmaceutical efficacy and previously reported marginal risks of pregnancy. RESULTS: Through two QI improvement cycles, within a pre-initiative cohort of 291 patients and post-initiative cohort of 156 patients, we increased any EC administration from 73.7% to 100% and effective EC from 44.1% to 100%, both of which were sustained for 14 months. Differences in effective EC administration across race and ethnicity groups pre-initiative (p = 0.005) were eliminated post-initiative (p = 0.840). An estimated 2.7-9.1 rape-related pregnancies were prevented in our post-initiative cohort. CONCLUSIONS: We achieved sustained effective EC administration to SA survivors and eliminated race and ethnicity disparities. Multi-modal interventions focusing on care standardization, education, and sustainability demonstrated success in patient preventative health goals and health equity.